In cases of obstruction, we derive much help from physical diagnosis. Having first learned the fact of constipation, we en deavor, by palpation, to discover the position of the distended bowel; the pelvis must be explored in search of a tumor which might press on the canal from without; and, lastly, the rectum itself must be examined to determine the presence of impacted feces, or discover the position of stricture by digital examination, and the introduction of instruments. The exploration ought never to be omitted when the bowels are obstructed ; and much light is always to be obtained from the simple, and it may be said necessary, employment of injections. When carefully performed, the amount of liquid that can be slowly injected into the canal may be said to be a direct measure of the extent of permeable intestine situated below the obstruction. In all cases in which it is towards the lower part of the bowels, vomiting, if prolonged or repeated, is apt to present a stercoraceous character.
One or two points afford occasional aid in determining the position and character of the obstruction. If the point at which pain is felt be also that at which we can trace the transition from a distended to a collapsed and empty state of the canal, we may feel pretty sure that this is the point of antra°. tion; the condition of the colon, which through its whole extent is coniparep lively fixed and immovable, especially demands examination with this view. Both symptoms, however, are apt to be indefinite—the pain extending over the whole abdomen—the relation of the distended portion to the rest of the intestine not to be recognized; and this is especially true when the small testine is affected.
A less trustworthy sign is derived from the urinary secretion, which is generally scanty when the obstruction is high up, and more abundant when it is situated lower down. This is very liable to be interfered with by other circumstances, such as the existence of fever. Still lees reliance is to be placed on the allegation that vomiting comes on earlier, and is more distress mg when the obstruction is high up.
Of the cases of sudden stoppage, it may be said in general terms, that about one-third are due to intussusception, one-third to some form of internal strangulation, and scarcely one-third to all other causes together. We incline to believe the cause of the obstruction to be invagination, if a little bloody mucus be passed by stool, if a sudden pain were felt before vomiting had been experienced, and when constipation had not been known to exist; we more readily assume that the gut is strangulated by a band of adhesion, if we can make out from the patient's history that be has had an attack of abdo minal inflammation at any previous period ; in their subsequent progress the former is more frequently associated with inflammatory fever than the latter.
By far the greater number of cases of gradual obstruction depend on stric ture, too frequently cancerous it is scarcely necessary to allude to an appearance occasionally observed, that the feces have been for some time previously of small diameter, because in such a case the constriction of the bowel must be quite within the reach of physical examination. But, it may be observed, that a previous history of long-continued diarrhoea, with un healthy discharges of pus, blood,. &c., may suggest the probability of con traction as a sequence of the ulcerative process at a higher portion of the canal.
Enteritis has to be distinguished from peritonitis, with which in some cases it stands in very close relation : it is very apt to be simulated by ealculous or gouty nephralipa. The other forms of obstructive disease are more nearly allied to hernia; it is, indeed, sometimes an internal hernia, which is only irremediable in so far as it is removed from manual interference great blame is justly due to the practitioner who omits examining every part where a hernia may possibly come within reach of relief in a case of insupera ble constipation.